Geriatric Assessment: An Office-Based Approach
Am Fam Physician. 2018 Jun 15;97(12):776-784.
Author disclosure: No relevant financial affiliations.
Family physicians should be proficient in geriatric assessment because, as society ages, older adults will constitute an increasing proportion of patients. Geriatric assessment evaluates medical, social, and environmental factors that influence overall well-being, and addresses functional status, fall risk, medication review, nutrition, vision, hearing, cognition, mood, and toileting. The Medicare Annual Wellness Visit includes the key elements of geriatric assessment performed by family physicians. Comprehensive geriatric assessment can lead to early recognition of problems that impair quality of life by identifying areas for focused intervention, but a rolling geriatric assessment over several visits can also effectively identify subtle or hidden problems. Assessment should be tailored to patient goals of care and life expectancy. By asking patients and families to self-assess risks using precompleted forms, and by using trained office staff to complete validated assessment tools, family physicians can maximize efficiency by focusing on identified problems. Fall risk can be assessed with a single screening question: “Have you fallen in the past year?” The Beers, STOPP (screening tool of older persons' prescriptions), and START (screening tool to alert doctors to right treatment) criteria are helpful resources for reviewing the appropriateness of medications in older adults. Screening for depression is recommended when depression care supports are available; this can be performed with a brief two-item screen, the Patient Health Questionnaire-2. Older adults should be screened for unintentional weight loss and malnutrition. Although rates of hearing loss and vision loss increase with age, there is insufficient evidence to recommend screening in asymptomatic individuals. The U.S. Preventive Services Task Force advises clinicians to assess cognition when there is suspicion of impairment. Urinary incontinence can impair patients' quality of life, and it can be assessed with a two-question screening tool. Immunizations and advance care planning are also important components of the geriatric assessment.
Older adults with complex chronic conditions will be an increasing proportion of family physicians' patient population. In 2015, patients older than 65 years accounted for 31% of all U.S. office visits, and that proportion will grow.1 Since 2013, every day 10,000 baby boomers turn 65 years of age and enter Medicare.2 By 2030, the population older than 65 years will double to 72 million (20% of the total U.S. population).2 Individuals are living longer, with multiple chronic illnesses, making them vulnerable to disability and diminished quality of life. Although 95% of older patients with complex needs have regular access to care, 58% struggle to navigate the system, and 62% are stressed about their ability to afford housing, utilities, or meals.3 Geriatric assessment, which evaluates medical problems; cognitive, affective, and functional abilities; and social and environmental factors, can identify these unrecognized needs to improve the well-being of older adults.
Evidence Base for Comprehensive Geriatric Assessment
Most of the literature supporting geriatric assessment models involves specialized geriatric team-based assessment. Comprehensive geriatric assessment is a systematic evaluation of frail older persons by a team of health professionals and consists of six core components: data gathering, team discussion, development of a treatment plan, and implementation of a treatment plan, with monitoring and revision as needed.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||References|
Physicians should screen older patients for a risk of future falls using a single question, “Have you fallen in the past year?” In-depth, multifactorial risk assessment for falls should be reserved for patients who respond affirmatively or those who take longer than 12 seconds to perform a Timed Up and Go Test.
Older adults should be screened for depression when appropriate support measures are available to ensure accurate diagnosis, effective treatment, and follow-up.
There is insufficient evidence to recommend screening for hearing loss in asymptomatic adults older than 50 years. Targeted screening should be performed in those with perceived hearing loss, and cognitive and affective symptoms.
Targeted screening for cognitive impairment is appropriate for patients with suspected impairment. The Mini-Cog tool is effective in primary care and appropriate for trained staff to
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